HomeMy WebLinkAboutBLD2012-00048 WILDING PERMIT APPLICA1N B 0048
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD12-00048 Received Date: 2/15/2012
SITE ADDRESS: 3464 HWY 104
PORT LUDLOW, 98365
OWNER: TEAL LAKE CENTER LLC PHONE: 360-265-8574
25825 CANYON RD NW
POULSBO WA 983709752
SUBDIVISION: Block: Lot: TX 37
PARCEL NUMBER: 821333027 Section: 33 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: MICHAEL PAKINAS PHONE: 360-531-1265
3464 TEAL LAKE RD
PORT LUDLOW WA 98365
PROJECT DESCRIPTIOt INTERIOR REMODEL & CHANGE OUT ROOF DORMER
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP ALT MAIN:
VALUATION 8,180.00 ADD'L: HEAT TYPE:
CODE EDITION: 2009 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid. —By:" Date: Receipt: Approved/Date
Permit $16'7.25 LYK 02/15/12 131456 APPROVEr
Plan Check $108.71 LYK 02/15/12 131456
State Building Code $4.50 LYK 02/15/12 131456 FED r+
15 L'1 i2
Total: $280.46 Jefferson County Planning
&Building Department
Jefferson County Building Dion Permit Num. BLD12-00048
Applicant: TEAL LAKE CENTER LLC
BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2009 International Building Codes
To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection.
Requests received after 7:00 AM will not be scheduled for that day's inspections.
ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries.
The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection
Inspection Item Date Approval Signature Notes
Setbacks
Erosion Control
Foundation Footing
Ext. Shear Wall Nailing ��,�z
Rough-in Plumbing 3 /� ( Z (7"(//
Framing - 7 /, / (/
Airseal .� �//
3- lS lZ La r�r i
a ,2.
Insulation: Walls _ .z •( , 4j 3
Insulation: Floors
Insulation: Ceiling .. .
Wallboard Nailing
Gas Line: Interior
Drywell/Alt Drainage J_ —
Address Posted I `�
FINAL INSPECTION
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
.
w ti ON
c JEFFERSON.UNTY
w4 ' O�`IA DEPARTMENT OF COMMUNITY DEVELOPMENT
ti 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
/4% �
, NO
Master Permit Application MLA: NQ MLA eg '
Pr ascription(includ separat eet`s as necessary):
�F V \v& J ` \5iv j .icc�C &_o c m Q C _ /
8' Z k 3 3 3 O -2. Property /� 0 �y<. 92.3 (acres/square feet)
Tax Parcel Number: � Pro art Size:
Site Address and/or Directions to Property: ( !3€5-7``D Pf'
Property Owner(s) of Record: 'T.,�►/ 1---skc. ede 4"2 '-,1.'r---
Telephone: 3/'e — 2 S`— �S'�i`J' 7Se Fax: r}� ,/� _ email:
Mailing Address: S 6V S c1fr J/ey vs X.d. I 4 S i O e,.- Cj'�,3 7 o
plicant1Agent(if different from owner): O✓) el.1-it i� b- �f�-/4 L/V/}s
Telephone:�3( -J Fax:T email:
Mailing Address: ��LPG TeAL - I''or t LU i owl w/}- 3/A6
What kind of ermit?(Check each box that applies ❑Lot or Road Segregation
NIBuilding Kepi:0 0 Critical Areas-Ste \ __
O Demolition Perme 0 Variance(Minor, Major o °il•vni s
❑ Single Family 0 Garage Attached/Detached 0 Conditional Use[C(a), ( ,
❑ Manufactured Home . .0 Modular - 0 Discretionary"D"or Ur` amed Use Classification
O Commercial* 0 Special Use(Essential Public Facilities).**
❑ Change of Use 0 Boundary Line Adjustment 2012
❑ Address 0 Road Approach 0 Short Plat** ,
O Home Business 0 Cottage Industry 0 Binding Site Plan** I 11—j
O Propane 0 Long Plat** JEFFERSON COUNTY
❑ Sign -. 0 Planned Rural Resided 'Ff Mend nts**
0 Allowed"Yes" Use Consistency Analysis 0 Plat Vacation/Alteration**
O Stormwater Management 0 Shoreline Master Program Exemption/Permit Revisions**
O Site Plan Approval Advance Determination(SPAAD)* • 0 Shoreline Management Substantial Development** •
❑Temporary Use 0 Shoreline Management Variance
0 Wireless Telecommunication* 0 Comprehensive Plan/UDC/Land Use District Map Amendment
O Forest Practices Act/Release of Six-Year Moratorium 0 Jefferson County Shoreline Master Program Amendment
*May require a Pre-Application Conference ❑Tree Vegetation Request
**Requires a Pre-Application Conference
Please identify any other local,state or federal permits required for this proposal, if known:
/� n DES,IG ATION OF AGENT
I hereby designate M IC 1-I A E b• f Af<iJ1/f4 to act as my agent in matters relating to this application/for permit(s).
x OWNER SIGNATURE •�/��(.�i J �.I,^- yl5 Date: / / Z—
/ By signing this application form,the owner/agent atte is that the information provided herein,and in any attachments,is true and correct to the best of
his,her or its knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs, reasonable attorney's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this-permit.
I further agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application
7review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the Co ty in writing at the
time of the applican that he or she nts prior n ti e. / j-
Signature: �(_�(��� Date: LT/ rl--- ` I
The action or actions Applicant will undert ke as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and Could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable s onsibility fo ering to and mplying with the ESA. The Applicant has read this dis le/i ng,c. s' as�and dates it below.
Signature: ��'�/ Date: /Lt F- Z
+G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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BUILDER STATEMENT
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are riot licensed contractors and that
they will be assumin he respo ility of the eneral Contractor for the proposed project. j�`--'
Date: / i_:.-t'/
Signature: '2 _
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: Fax:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTORS LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: 4,cm,...;,,,,,S "f--vtli w yerti 1,,. PHONE ,(360) Z3
cy� 0.23 FAX:(49)YS 3o�7
MAILING ADDRESS: / EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
O New K Wood Existing: ___L_ ❑ Sewer
O Addition 0 Steel Proposed: Bank ❑ Community System
Alteration/Remodel ❑ Concrete Total: / Heig� *'Individual System
' Repair ❑ Masonry �YY SEEP Permit#
O Demolition ❑ Other: Bedrooms: Water Supply:
Existing: -a Setback: ❑ Private well Q> rwo Party
Type of He t: / , t Proposed: ❑ Public
.zoNe G tr4/ x Total: AAA Name of System: '
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: " Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No '
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
1 U• nderground Tank 1 Above ground Tank Size of Propane Tank:
1 Heat Stove 1 Cook Stove I Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove 1 Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size, distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed ,,'Eke Office Use O 'm,.. x ,. rtfourit • Reviision " -
Main Floor Heated I)2.3
123 ' - y EH Bld App Review: _
Floor Heated , 6 0 " ', Consistency Review:
OttlerRHeated
I-CO / 2 8 0 A Base fee: I VT.c3
Mezzanine Additional Section:
Heated Basement Plan Check fee: r7 •
Unheated Basement State Surcharge fee: /( 56
Other Unheated* --Pot Water Review fee: `
Garage/Carport , SUBTOTAL
Decks F 911/Rd Approach fee:
6 27 ,
Other + '
TOTAL: $ (3go , ` (.0
— N Receipt Number: 13 1 `150
, Cash/Check Number: 10011
`__
ESTIMATED COST(REQUIRED Date: l�l
.Fair arket value of all labQrandrrratenals foundation to finish
p '(�b r C t2 Initials: �„_
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